MEDIATOR APPLICATION FORM

PAGE 3

d. Areas of Expertise and Experience in Each Area

PLEASE ENTER THE ESTIMATED NUMBER OF MEDIATIONS FOR EACH TYPE:

e. Awards

ORGANIZATION

AWARD (DESCRIPTION)

DATE

SECTION IV

REFERENCES

List 3 persons who are familiar with your mediation skills

NAME

ORGANIZATION

PHONE NUMBER

EMAIL ADDRESS

SECTION V

ETHICAL CONSIDERATIONS

I. I here certify that:

a. No disciplinary action has ever been taken against me by any state, federal, or professional licensing board/agency.

b. I have not been convicted of a felony or misdemeanor at any time in the past.

II. I hereby certify that I have read, and will abide by, the Ethical Standards used in Court mediation programs as stated in the California Rules of Court, Chapter 3, Articles 1 and Article 2.

III. I understand that if accepted to the panel that I may be required to provide volunteer services to educate the public about mediation as an alternative to litigation and when appropriate I may offer mediation to those who qualify without charge.

IV. I hereby certify that the foregoing is true and correct to the best of my knowledge.

PLEASE UPLOAD A RECENT PHOTO OF YOURSELF:

PLEASE UPLOAD A SHORT BIO OF YOUR MEDIATION SERVICES - NO MORE THAN 200 WORDS - TO POST ON THE MCLA WEBSITE:

Please allow a few seconds for the form to SUBMIT.